Circulation

IN DEPTH

Harmonization of the American College of

Cardiology/American Heart Association and
European Society of Cardiology/European
Society of Hypertension Blood Pressure/
Hypertension Guidelines: Comparisons,
Reflections, and Recommendations
Paul K. Whelton , MB, MD, MSc; Robert M. Carey, MD; Giuseppe Mancia , MD; Reinhold Kreutz , MD;
Joshua D. Bundy , PhD, MPH; Bryan Williams , MD

ABSTRACT: The 2017 American College of Cardiology/American Heart Association and 2018 European Society of Cardiology/European
Society of Hypertension clinical practice guidelines for management of high blood pressure/hypertension are influential documents.
Both guidelines are comprehensive, were developed using rigorous processes, and underwent extensive peer review. The most notable
difference between the 2 guidelines is the blood pressure cut points recommended for the diagnosis of hypertension. There are also
differences in the timing and intensity of treatment, with the American College of Cardiology/American Heart Association guideline
recommending a somewhat more intensive approach. Overall, there is substantial concordance in the recommendations provided by
the 2 guideline-writing committees, with greater congruity between them than their predecessors. Additional harmonization of future
guidelines would help to underscore the commonality of their core recommendations and could serve to catalyze changes in practice
that would lead to improved prevention, awareness, treatment, and control of hypertension, worldwide.

Key Words: antihypertensive agents ◼ blood pressure ◼ cardiovascular diseases ◼ hypertension ◼ life style ◼ practice guideline ◼ public health

F
ew areas are of greater importance for the health of
the public and provide better opportunity for deci-
sions based on sound scientific principles than the
prevention and management of high blood pressure
(BP)/hypertension. In partnership with 9 other profes-
sional societies, the American College of Cardiology
(ACC) and American Heart Association (AHA) published
the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/
ASH/ASPC/NMA/PCNA Guideline for the Prevention,
Detection, Evaluation, and Management of High Blood
Pressure in Adults1 and 1 year later the European Soci-
ety of Cardiology (ESC) and European Society of Hyper-
tension (ESH) published the 2018 ESC/ESH Guidelines
for the Management of Arterial Hypertension.2 The 2017
ACC/AHA and 2018 ESC/ESH guidelines are among
the most influential and highly cited BP/hypertension
clinical practice guidelines (CPGs) worldwide.
Perspective, see p 805
These 2 comprehensive guidelines have areas of dif-
ference but more often provide similar advice.3 In this

The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
Correspondence to: Paul K. Whelton, MB, MD, MSc, 1440 Canal St, Rm 2015, New Orleans, LA 70112. Email pkwhelton@gmail.com
Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCULATIONAHA.121.054602.
For Sources of Funding and Disclosures, see page 877.
The article has been co-published with permission in the European Heart Journal, the Journal of the American College of Cardiology, and Circulation. © 2022 This is
an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits non-commercial reuse, distribution,
and reproduction in any medium, provided the original work is properly cited. The articles are identical except for minor stylistic and spelling differences in keeping with
each journal’s style. When citing this article, a citation from any of the journals listed is appropriate.
Circulation is available at www.ahajournals.org/journal/circ

868 September 13, 2022 Circulation. 2022;146:868–877. DOI: 10.1161/CIRCULATIONAHA.121.054602

Whelton et al
Nonstandard Abbreviations and Acronyms
ACC American College of Cardiology
ACE angiotensin-converting enzyme
AHA American Heart Association
ARB angiotensin receptor blocker
ASCVD atherosclerotic cardiovascular disease
BP blood pressure
CCB calcium channel blocker
CKD chronic kidney disease
CPG clinical practice guideline
CVD cardiovascular disease
DBP diastolic blood pressure
DM diabetes mellitus
ESC European Society of Cardiology
ESH European Society of Hypertension
HMOD hypertension-mediated organ damage
SBP systolic blood pressure
SCORE Systematic Coronary Risk Evaluation
review, we provide a comparison of these 2 CPGs by
contrasting the processes used to formulate the guide-
lines and by reviewing the recommendations provided
for BP measurement and classification, patient evalu-
ation, estimation of cardiovascular disease (CVD) risk,
BP threshold for initiating antihypertensive drug therapy,
BP goals of therapy, and the use of lifestyle modification
and pharmacological therapy. We also provide reflections
and recommendations to future guideline committees on
ways to harmonize recommendations in US and Euro-
pean BP guidelines.
PROCESS AND REPORT FORMAT
Both guidelines were based on a rigorous approach to
the generation of recommendations, with some differ-
ences in the specifics of the process (Table S1). The
ACC/AHA guideline was developed by a 21-member
writing committee composed of primary and specialty
care physicians, epidemiologists, a nurse, a physician
assistant, a pharmacist, and 2 lay/patient members.
Members were chosen for their expertise and for their
capacity to represent the 2 principal sponsors (ACC
and AHA) and the 9 collaborating professional societ-
ies. The ESC/ESH report was developed by a 28-mem-
ber committee of physician and nurse members, half
selected by the ESC and half selected by the ESH, from
14 European countries, who had special expertise in the
prevention and treatment of hypertension or the gen-
eration of CPGs. A requirement for participation in the
ACC/AHA writing committee was absence of a rela-
tionship with BP-related commercial entities. The ESC/
ESH writing committee required disclosure of any such
relationships. Both guidelines followed a formal process
Circulation. 2022;146:868–877. DOI: 10.1161/CIRCULATIONAHA.121.054602
ACC/AHA and ESC/ESH Blood Pressure Guidelines
for the development of their recommendations that was
stipulated by their sponsoring professional societies.
STATE OF THE ART
Both writing committees conducted extensive reviews
of the existing literature. The ACC/AHA process speci-
fied conduct of systematic reviews and meta-analyses
by an independent Evidence Review Committee. The
ESC/ESH guideline committee had the option to com-
mission additional evidence reviews but concluded that
published peer-reviewed systematic reviews and meta-
analyses already provided sufficient evidence for de-
cision-making. The ACC/AHA process also stipulated
the generation of detailed evidence tables as a supple-
ment to the guideline recommendations; a total of 448
such tables were published. Both guidelines underwent
extensive peer review and required final approval by the
governing boards of their sponsoring professional or-
ganizations.
The ACC/AHA guideline provides 106 formal rec-
ommendations and the ESC/ESH provides 122. In both
guidelines, each recommendation is characterized by a
class of recommendation that specifies the strength or
importance of the recommendation and by a level-of-evi-
dence designation. Both the ESC/ESH and ACC/AHA
guideline committees voted on the wording and grad-
ing of each recommendation. Both guidelines provide
comprehensive advice for prevention, diagnosis, evalu-
ation, and management of high BP/hypertension. As a
result, the 2 full reports are relatively long (103 pages
for the ACC/AHA and 84 pages for the ESC/ESH). For
ease of reading, however, the documents are divided
into sections and subsections that use a similar presen-
tation format. In addition, a variety of shorter executive
summaries and brief synopses have been published.
Guideline authors have published articles that expand
on individual guideline topics, provide perspective for
the evidence underpinning selected recommendations,
and furnish quantitative estimates of potential impact
based on universal application of guideline recommen-
dations in their target populations. Last, both guidelines
are complemented by publicly available slide sets, CVD
risk estimation calculators, and other educational tools.
BP MEASUREMENT AND
CORRESPONDENCE OF OFFICE AND
OUT-OF-OFFICE READINGS
Errors in BP measurement are a major source of BP
misclassification. Both guidelines place strong empha-
sis on accurate measurement of BP by using validated
devices and multiple readings for diagnosis and man-
agement of hypertension (Tables 1–3). The ACC/AHA
recommends averaging office BP readings, using the
same advice for ≥2 readings on ≥2 occasions provid-
ed in previous Joint National Committee reports, and
recommends confirmation of office hypertension by
means of out-of-office measurements. The ESC/ESH
September 13, 2022 869
 Whelton et al ACC/AHA and ESC/ESH Blood Pressure Guidelines

Table 1. BP Measurement Table 3. European Society of Cardiology/European Society

of Hypertension Table of Out-of-Office Equivalence for an
American College of
STATE OF THE ART

Office Systolic Blood Pressure/Diastolic Blood Pressure of

Cardiology/American Heart European Society of Cardiology/
140/90 mm Hg
Association European Society of Hypertension
Strong emphasis on measure- Strong emphasis on measurement Ambulatory blood pressure monitoring
ment accuracy. accuracy. Office Home Daytime Nighttime 24 hours
Use of repeated office read- Use of repeated readings (3 readings, 140/90 135/85 135/85 120/70 130/80
ings (≥2 readings on ≥2 with additional readings when first 2 differ
occasions). by ≥10 mm Hg or BP unstable because All measurements are mm Hg. Table modified from Williams et al2 with per-
of an arrhythmia). BP is recorded as the mission. Copyright © 2018, Oxford University Press to facilitate comparison.
average of the last 2 BP readings.
Confirmation of office hyper- Confirmation of hypertension by means of
tension by means of out-of- repeated office, or out-of-office (ABPM or BP CLASSIFICATION
office (HBPM or ABPM) BP HBPM) BP measurements.
measurements. The most obvious difference between the 2 guidelines is
Out-of-office measurements to Out-of-office BP measurements to recog- their approach to BP classification and the BP cut points
recognize masked and white nize masked and white coat hypertension. recommended for the identification of hypertension (Ta-
coat hypertension. ble 4). The ACC/AHA proposes categories for normal
Heart rate should be also recorded dur- BP, elevated BP, and 2 stages of hypertension, with a
ing BP measurements.
cut point of systolic blood pressure (SBP) ≥130 mm Hg
ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and/or diastolic blood pressure (DBP) ≥80 mm Hg for
and HBPM, home blood pressure monitoring. Adapted from Whelton et al1 with identification of hypertension. This is a change from the
permission. Copyright © 2018, Elsevier; and Williams et al2 with permission.
Copyright © 2018, Oxford University Press. preceding 2003 Joint National Committee 7 CPG, which
­recommended use of an SBP and/or DBP cut point of
recommends 3 readings for office BP measurement, 140 and/or 90 mm Hg, except in adults with diabetes mel-
with additional readings when the first 2 differ by >10 litus (DM) or chronic kidney disease (CKD), where an SBP
mm Hg or BP is unstable because of an arrhythmia, and and/or DBP cut point of 130 and/or 80 mm Hg was rec-
advises confirmation of office hypertension by means ommended. The ESC/ESH classifies BP into optimal BP,
of either repeated office readings at several visits or normal BP, high normal BP, 3 grades of systolic/diastolic
by out-of-office BP measurements. Both guidelines hypertension, and isolated systolic hypertension. It retains
recommend out-of-office BP measurements to recog- the same SBP ≥140 mm Hg and/or DBP ≥90 mm Hg cut
nize masked and white coat hypertension. They provide points for diagnosis of hypertension recommended in the
only slightly different treatment guidance for white coat preceding 2013 ESH/ESC hypertension CPG.
and masked hypertension, while mentioning the uncer- The potential US population impact of the ACC/AHA
tainty of such recommendations. The ACC/AHA CPG guideline was estimated by an analysis of the 2011 to
provides corresponding values for office and out-of- 2014 National Health and Nutrition Examination Survey.
office measurements (home blood pressure monitoring, In this analysis, 24.1% of US adults ≥20 years of age
ambulatory blood pressure monitoring) in the range of reported that they were taking antihypertensive medica-
120/80 mm Hg to 160/100 mm Hg for office BP mea- tion and were therefore considered to have hypertension.
surements, whereas the ESC/ESH provides only the Of those not taking antihypertensive medication, 7.7% had
corresponding cutoff values for the diagnosis of hyper- an SBP ≥140 mm Hg or DBP ≥90 mm Hg, and 13.7%
tension for home blood pressure monitoring and ambu- had an SBP 130 to 139 mm Hg or DBP 80 to 89 mm Hg,
latory blood pressure monitoring measurements. The yielding a 46% prevalence of hypertension for adults
latter are, however, concordant with the corresponding using the SBP ≥130 mm Hg and/or DBP ≥80 mm Hg
values in the ACC/AHA guideline (Tables 1–3). cut points, or taking antihypertensive medication defini-
tion of hypertension compared with a prevalence of 32%
Table 2. American College of Cardiology/American Heart using the SBP ≥140 mm Hg and/or DBP ≥90 mm Hg,
Association Table of Blood Pressure Equivalence for Clinic or taking antihypertensive medication definition.4 Preva-
and Out-of-Office Readings lence estimates using the 2 definitions of hypertension
Ambulatory blood pressure monitoring were more discrepant at younger age than at older age,
Clinic Home Daytime Nighttime 24 hours
and in men compared with women. Taken altogether, the
ACC/AHA reclassification of BP resulted in an estimated
120/80 120/80 120/80 100/65 115/75
population increase in hypertension prevalence of ≈14%.
130/80 130/80 130/80 110/65 125/75
The National Health and Nutrition Examination Survey
140/90 135/85 135/85 120/70 130/80 analyses, however, are likely to overestimate hypertension
160/100 145/90 145/90 140/85 145/90 prevalence because participant BP was only measured
All measurements are mm Hg. Table adapted from Whelton et al1 with permis- on a single occasion and presumed hypertension was not
sion. Copyright © 2018, Elsevier. confirmed by out-of-office BP readings.

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Whelton et al ACC/AHA and ESC/ESH Blood Pressure Guidelines

Table 4. Blood Pressure Classification trasound, pulse wave velocity, ankle-brachial index, cog-
Systolic blood Diastolic nitive function testing, and brain imaging are additional

STATE OF THE ART

pressure, blood pres- tests that can be used for recognition of hypertension-
Categories mm Hg And/or sure, mm Hg mediated organ damage (HMOD). Thus, the assessment
American College of Cardiology/American Heart Association of HMOD and its implementation in risk stratification
Normal <120 and <80 was an important consideration for CVD risk prediction
Elevated 120–129 and <80 in the ESC/ESH CPG.
Hypertension, stage 1 130–139 or 80–89
Hypertension, stage 2 ≥140 or ≥90 CVD RISK ASSESSMENT
European Society of Cardiology/European Society of Hypertension
CVD risk assessment identifies individuals at increased
Optimal <120 and <80 risk for the major complications of hypertension, including
Normal 120–129 and/or 80–84 target organ damage and death. Both guidelines recom-
High normal 130–139 and/or 85–89 mend CVD risk assessment as a complement to the level
Hypertension, grade 1 140–159 and/or 90–99 of BP for antihypertensive treatment decisions, with the
Hypertension, grade 2 160–179 and/or 100–109
ESC/ESH guideline also emphasizing the importance of
CVD risk prediction for consideration of concomitant in-
Hypertension, grade 3 ≥180 and/or ≥110
terventions such as statin and antiplatelet therapies. The
Isolated systolic hypertension ≥140 and <90
2 guidelines differ in their methods for estimation of risk,
Table adapted from Whelton et al with permission. Copyright © 2018,
1
and as outlined later, their use of the risk information in
Elsevier; and Williams et al2 with permission. Copyright © 2018, Oxford decision-making for antihypertensive drug treatment.
University Press.
The ACC/AHA prescribes a relatively simple approach
Overall, the ACC/AHA categorization is simpler and in which the presence of CVD automatically indicates
captures more of the BP-related risk for CVD. However, high risk (Table 5). In the absence of CVD, ASCVD risk
it results in a larger challenge for health care profes- in adults 40 to 79 years of age is estimated using the
sionals compared with the ESC/ESH or preceding Joint ACC/AHA Pooled Cohort Equations,6 which have been
National Committee 7 Report because (1) it designates validated in White and Black US adults. The ACC/AHA
hypertension in a higher percentage of adults and (2) ASCVD Risk Estimator Plus7 is based on age; levels of
there is need to assess underlying atherosclerotic CVD SBP, DBP; total, high-density, and low-density cholester-
(ASCVD) risk for treatment decisions, especially in adults ol; history of DM; current smoking; and treatment with an-
with ACC/AHA stage 1 hypertension (outlined in the tihypertensive drug therapy, statins, or aspirin. The ACC/
CVD risk assessment section). The ESC/ESH classifi- AHA Guideline Writing Committee estimated a 10-year
cation system has more BP categories but provides a ASCVD risk of ≈10% in the landmark event–based anti-
simpler approach to decisions for the administration of hypertensive drug treatment trials, leading to the choice
antihypertensive drug therapy, unchanged from the previ- of a higher and lower 10-year ASCVD risk of ≥10% and
ous European guideline recommendations. <10%, respectively. Hypertension in adults with DM,
CKD, or age of ≥65 years is accepted as a surrogate
disease marker for higher ASCVD risk. For adults <40
years of age, the ACC/AHA recommends estimation of
PATIENT EVALUATION lifetime CVD risk. The ESC/ESH uses 4 categories of
Both guidelines recommend obtaining a personal and CVD risk (Figure 1). Adults with existing CVD, including
family history, performing a physical examination that asymptomatic atheromatous disease on imaging, type 1
includes measurement of BP, and obtaining basic labo- or 2 DM, very high levels of individual CVD risk factors,
ratory testing (Table S2). Although the specifics of the or CKD are considered to be at high or very high risk
latter overlap in requiring a fasting blood glucose, blood/ (10-year CVD mortality of 5%–10% and ≥10%, respec-
serum sodium and potassium, lipid profile, serum creati- tively). For all others, 10-year CVD mortality risk should
nine/estimated glomerular filtration rate, urinalysis, and be estimated using the Systematic Coronary Risk Evalu-
ECG, there are discrepancies with the ACC/AHA (only) ation (SCORE) risk estimator. The SCORE risk is esti-
recommending a complete blood count, serum calcium, mated using a patient’s age, sex, total cholesterol or total
and thyroid stimulating hormone, and the ESC/ESH and high-density lipoprotein cholesterol, smoking status,
(only) recommending a hemoglobin/hematocrit, blood and level of SBP. Although not included in SCORE, the
uric acid, glycated hemoglobin A1c, liver function tests, ESC/ESH guidelines recommend that heart rate should
urine protein test or, ideally, urinary albumin-to-creatinine also be recorded during BP measurements (Table 1–3)
ratio. An echocardiogram, uric acid, and urinary albumin- and a resting heart rate >80 beats/min should be con-
to-creatine ratio are optional tests in the ACC/AHA sidered as a cardiovascular risk factor. Validated SCORE
guideline. In the ESC/ESH, echocardiography, carotid ul- risk charts are available for both high-risk and low-risk

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 Whelton et al
Table 5. CVD/ASCVD Risk Assessment
STATE OF THE ART
American College of Cardiology/American Heart Association
CVD risk based on history of CVD or 10-year ASCVD risk ≥10%
using the ACC/AHA Pooled Cohort Equations5 in adults 40–79
years of age.
Higher-risk category*: CVD or 10-year ASCVD risk ≥10%
Lower-risk category*: no CVD and 10-year ASCVD risk <10%
Risk stratification recommended for all adults with hypertension but
especially important for treatment decisions in adults with stage 1
hypertension (confirmed systolic blood pressure 130–139 mm Hg
or diastolic blood pressure 80–89 mm Hg).
Lifetime risk assessment encouraged in younger adults.
ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; CVD,
cardiovascular disease. Table adapted from Whelton et al1 with permission. Copyright © 2018, Elsevier; and Williams et al2 with permission.
Copyright © 2018, Oxford University Press.
*Based on ACC/AHA Pooled Cohort Equations.5
European countries and 15 national or regional SCORE
risk charts are also available.8 The ESC/ESH places em-
phasis on the importance of considering HMOD in the
assessment of CVD risk. Comorbidities such as CKD,
left ventricular hypertrophy, and DM are included in the
SCORE risk assessment tool (Table 5). The guideline
also includes a table of SCORE risk calculation correc-
tion factors according to ethnicity. Last, the ESC/ESH
guideline uses a classification system based on levels of
BP, categories of HMOD, other CVD risk factors, and/
or CVD, to illustrate the amplification of risk when risk
factors aggregate. Both the ESC/ESH and ACC/AHA
guidelines recognize challenges with the use and inter-
pretation of CVD/ASCVD risk-estimating tools.
LIFESTYLE INTERVENTION
In a high percentage of adults, high BP is related to an
unhealthy diet, lack of physical activity, and/or use of al-
cohol. Therefore, both guidelines identify lifestyle modi-
fication as the cornerstone for prevention and treatment
of hypertension (Table S3). In the ACC/AHA, a healthy
diet, especially the Dietary Approaches to Stop Hyper-
tension diet, weight loss in adults who are overweight/
obese, dietary sodium reduction, enhanced dietary po-
tassium intake, physical activity, and moderation or ab-
stinence from alcohol are recommended for prevention
and management of hypertension. Similarly, in the ESC/
ESH, a healthy diet, especially the Mediterranean diet,
weight loss in adults who are overweight/obese, dietary
sodium reduction, physical activity, and moderation in
alcohol consumption are identified as the core strategy
for prevention and management of hypertension. Both
guidelines recommend smoking cessation for the pre-
vention of CVD.
872 September 13, 2022
ACC/AHA and ESC/ESH Blood Pressure Guidelines
European Society of Cardiology/European Society of
Hypertension
Adults with existing CVD, type 1 or type 2 diabetes mellitus, very
high levels of individual CVD risk factors (eg, grade 3 hyperten-
sion), or hypertension-mediated organ damage (eg, chronic kidney
disease, stages 3–5) are considered to be at high or very high risk
(10-year CVD mortality of 5%–10% and ≥10%, respectively).
For all others, 10-year CVD risk should be estimated using the
Systematic Coronary Risk Evaluation system for prediction of a first
fatal CVD event.
THRESHOLD FOR INITIATION OF
ANTIHYPERTENSIVE DRUG THERAPY
The addition of antihypertensive drug therapy to non-
pharmacological lifestyle counseling is recommended
for all adults with an SBP ≥140 mm Hg or DBP ≥90
mm Hg, irrespective of CVD/ASCVD risk, in the ACC/
AHA guideline (Tables 6–8). For the same BP cut
points, the ESC/ESH guideline recommends the imme-
diate initiation of antihypertensive drug therapy in high-
risk or very-high-risk patients with CVD, renal disease,
or HMOD, and if BP is not controlled after 3 months
of lifestyle intervention in patients at low or moderate
risk for CVD. An exception is that adults >80 years of
age who have untreated hypertension should only be
considered for BP lowering when their office SBP is
≥160 mm Hg. In the ACC/AHA guideline, drug therapy
is also recommended for the ≈30% of adults with an
SBP 130 to 139 mm Hg or DBP 80 to 89 mm Hg who
are identified as being at higher risk for CVD/ASCVD.
This has a particular effect on increased drug treatment
for older patients, because age is such a strong and
nonmodifiable determinant of risk.4 In the ESC/ESH,
drug therapy may only be considered for adults with an
SBP 130 to 139 mm Hg or DBP 85 to 89 mm Hg in
patients with CVD, especially those with coronary artery
disease. Figure 2 provides 2 algorithms that highlight
the recommended approaches to the management of
adults with different categories of BP and CVD/AS-
CVD risk with nonpharmacological therapy/lifestyle
advise and antihypertensive drug therapy. It is chal-
lenging to derive a precise quantitative estimate for the
resulting difference in treatment rates with antihyper-
tensive medication. Based on the previously mentioned
National Health and Nutrition Examination Survey
Circulation. 2022;146:868–877. DOI: 10.1161/CIRCULATIONAHA.121.054602
Whelton et al ACC/AHA and ESC/ESH Blood Pressure Guidelines

STATE OF THE ART

Figure 1. Categories of cardiovascular disease risk in the 2018 ESC/ESH hypertension guideline.
BP indicates blood pressure; CKD, chronic kidney disease; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; ESC,
European Society of Cardiology; ESH, European Society of Hypertension; HMOD, hypertension-mediated organ damage; LVH, left ventricular
hypertrophy; PAD, peripheral artery disease; SCORE, Systematic Coronary Risk Evaluation; and TIA, transient ischemic attack. Reprinted from
Williams et al2 with permission. Copyright © 2018, Oxford University Press.

analysis, the difference between the prevalence of anti-
hypertensive drug therapy recommendations using the
2017 ACC/AHA and Joint National Committee 7 BP
guidelines was estimated to be 1.9%.4 Whatever the
absolute difference between the ACC/AHA and ESC/
ESH guidelines, the ACC/AHA CPG recommends anti-
hypertensive drug therapy in addition to lifestyle coun-
seling in a higher percentage of adults with an SBP/
DBP <140/90 mm Hg.
ANTIHYPERTENSIVE DRUG TREATMENT
STRATEGY
As outlined in Tables 6–8, both guidelines recommend
use of agents from the following 4 drug classes: diuret-
ics, calcium channel blockers (CCBs), angiotensin-con-
verting enzyme (ACE) inhibitors, or angiotensin receptor
blockers (ARBs) in adults with no compelling indication
for selection of a specific BP-lowering medication.
The ACC/AHA indicates a preference for the longer-
acting thiazide-type diuretic chlorthalidone compared
with other diuretic agents because chlorthalidone was
the diuretic used in many of the landmark event–based
randomized clinical trials. Both guidelines advise com-
bination therapy in most adults with hypertension (usu-
ally, an initial combination of ACE inhibitors or ARB, a
diuretic, and/or a CCB). The ACC/AHA specifically rec-
ommends combination therapy for Black patients and
for adults with more severe hypertension (SBP ≥140
mm Hg or DBP ≥90 mm Hg and an average SBP/DBP
>20/10 mm Hg above their target BP). In addition, the
ACC/AHA guideline recommends that initial antihyper-
tensive drug therapy in Black patients should include a
thiazide-type diuretic or CCB. The ESC/ESH guideline
also recommends that initial treatment in most Black
patients should be with a 2-drug combination, compris-
ing a diuretic and CCB, either in combination with each
other or with an ACE inhibitor or ARB. The ACC/AHA
notes that single-pill combinations improve treatment
adherence but may contain lower-than-optimal doses
of the thiazide diuretic component. The ESC/ESH rec-
ommends a core drug combination treatment strategy
for most patients including patients with uncomplicated
hypertension, patients with HMOD, cerebrovascular
disease, diabetes, or peripheral artery disease. This
strategy comprises initial dual combination therapy
(ACE inhibitors or ARB and CCB or diuretic), preferably
in a single-pill combination, followed, if still above tar-
get BP, by triple therapy (ACE inhibitors or ARB, CCB
and diuretic) using a single-pill combination, followed if
still above the target by the addition of spironolactone
or other diuretic, α-blocker, or β-blocker and consider-
ation of referral to a specialist center. Both guidelines

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 Whelton et al
Table 6. Antihypertensive Drug Therapy for Management of Hypertension
STATE OF THE ART
American College of Cardiology/American Heart Association
Threshold for addition of antihypertensive drug therapy
 All adults with SBP ≥140 mm Hg or DBP ≥90 mm Hg.
 Adults with SBP 130–139 or DBP 80–89 mm Hg and CVD or
a 10-year atherosclerotic CVD risk ≥10%, based on estimation
using of the ACC/AHA Pooled Cohort Equations calculator.6
Treatment strategy
 If there is no compelling clinical indication for selection of a
BP-lowering medication, treat with ≥1 drugs from the following
classes: diuretics, CCBs, ACE inhibitors, or ARBs. Combination
therapy is required in most patients and is specifically recom-
mended in African Americans and in adults with a starting SBP/
DBP ≥20/10 mm Hg above the BP treatment target. Dual- and
triple-drug therapy should include agents with complementary
mechanisms of action. Single-pill combinations improve adher-
ence but may contain lower -than-optimal doses of thiazide di-
uretic. Simultaneous use of an ACE inhibitors, ARB, and/or renin
inhibitor is potentially harmful and not recommended.
ACE indicates angiotensin converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CCB, calcium channel blocker;
CVD, cardiovascular disease; DBP, diastolic blood pressure; and SBP, systolic blood pressure. Table adapted from Whelton et al1 with per-
mission. Copyright © 2018, Elsevier; and Williams et al2 with permission. Copyright © 2018, Oxford University Press.
recommend against simultaneous use of ACE inhibitors
and ARB. Likewise, both guidelines provide specific
advice on choice of BP-lowering medications in adults
with hypertension and various comorbidities/conditions,
and in special patient groups, as well. In the ESC/ESH
guidelines, β-blockers are considered to be first-line
antihypertensive drugs in patients with a specific indi-
cation for their use, because, in comparison with other
BP-lowering drugs, β-blockers are usually equivalent in
preventing major cardiovascular events with the excep-
tion of less efficacy for stroke prevention. Therefore,
their use is primarily recommended in specific (most
importantly cardiac) indications and in pregnant women
or women planning pregnancy.
OFFICE BP TREATMENT TARGETS
Both the ACC/AHA and ESC/ESH recommend lower
BP treatment targets compared with the goals advised in
Table 7. American College of Cardiology/American Heart
Association Office Blood Pressure Treatment Targets for
Antihypertensive Drug Therapy for Management of
Hypertension
A systolic blood pressure /diastolic blood pressure <130/80 mm Hg target
recommended for all adults with hypertension, with the exception that a
systolic blood pressure <130 mm Hg target is recommended for nonin-
stitutionalized, ambulatory, community-living older adults (≥65 years). For
older adults with hypertension and a high burden of comorbidity/limited life
expectancy, it is reasonable to base treatment intensity and choice of drugs
on clinical judgment, patient preference, and a team-based approach to as-
sessing risk/benefit.
Table adapted from Whelton et al1 with permission. Copyright © 2018,
Elsevier; and Williams et al2 with permission. Copyright © 2018, Oxford
University Press.
874 September 13, 2022 Circulation. 2022;146:868–877. DOI: 10.1161/CIRCULATIONAHA.121.054602
ACC/AHA and ESC/ESH Blood Pressure Guidelines
European Society of Cardiology/European Society of
Hypertension
All adults with SBP ≥140 mm Hg or DBP ≥90 mm Hg. Consider in
adults with SBP 130–139 mm Hg or DBP 85–89 mm Hg who are
at very high risk because of CVD, especially those with coronary
heart disease.
If no compelling clinical indication for selection of a BP-lowering
medication, treat with drugs from the following classes: ACE in-
hibitors, ARB, CCB, or diuretics. Initial combination therapy with
ACE inhibitors or ARB plus CCB or diuretic recommended in most
patients with hypertension, with the use of single-pill combina-
tions strongly favored. If BP is still above goal, switch to single-pill
combination therapy with ACE inhibitors or ARB plus CCB and
diuretic. If BP still above goal, add spironolactone or other diuretic,
α-blocker or β-blocker and consider referral to a specialist center
for further evaluation.
The combination of 2 renin-angiotensin system blockers is not
recommended.
previous guidelines. The ACC/AHA recommends SBP/
DBP <130/80 mm Hg as a general treatment target,
if tolerated (Tables 6–8). For older adults (≥65 years),
who are noninstitutionalized, ambulatory, and community
dwelling, the target is SBP <130 mm Hg, if tolerated.
For older adults with a high burden of comorbidity and
limited life expectancy, treatment decisions should be
based on clinical judgment, patient preference, and a
team-based assessment of risk/benefit. The ESC/ESH
recommends target ranges but recognizes that the op-
timal and tolerated targets for individuals will differ. The
initial SBP/DBP target is <140/90 mm Hg for all adults
with hypertension. Provided the treatment is well toler-
ated, targeting to 130/80 mm Hg is recommended, with
subsequent efforts to achieve a lower BP in those 18 to
65 years of age. An exception to the general rule is that
the SBP target in adults with hypertension and CKD
should be <140 to 130 mm Hg. The ESC/ESH advises
against specifically targeting SBP to <120 mm Hg for
adults, but acknowledges that this may be achieved in
some treated patients without adverse effects. A key
emphasis, especially in older and frailer patients, is to
tailor the treatment to achieve the best BP possible
within the target range, while monitoring for adverse ef-
fects. The optimal DBP target is defined as 70 to 79
mm Hg for all patients, but the emphasis is on controlling
SBP, even when DBP is below these levels, provided the
treatment is tolerated.
OTHER TOPICS
Both guidelines provide recommendations for follow-up
intervals, with the ACC/AHA CPG suggesting 1 year for
Whelton et al ACC/AHA and ESC/ESH Blood Pressure Guidelines

Table 8. European Society of Cardiology/European Society of Hypertension Office Blood Pressure

Treatment Targets for Antihypertensive Drug Therapy for Management of Hypertension

STATE OF THE ART

Systolic blood pressure, mm Hg
Diastolic blood
+Coronary heart +Stroke/transient +Chronic kidney pressure,
Age, y Hypertension +Diabetes disease ischemic attack disease mm Hg
18-65 130 or lower, if tolerated but not <120 <140 to 130, if 70–79
tolerated

≥65 130–139, if tolerated 70–79

First target office systolic blood pressure/diastolic blood pressure <140/90 mm Hg, with final target range as shown in this table. Table
adapted from Williams et al2 with permission. Copyright © 2018, Oxford University Press.

reevaluation of adults with a normal BP, 3 to 6 months
for those treated with ­nonpharmacological therapy, and
1 month after initiation of antihypertensive drug therapy
followed by 3 to 6 months after meeting the BP goal.
The ESC/ESH CPG suggests follow-up within the first
2 months after the initiation of antihypertensive drug
therapy, with the caveat that the interval should de-
pend on the severity of hypertension and urgency to
achieve BP control. After the desired BP target has
been achieved, an interval of a few months is suggest-
ed for BP monitoring and 2 years for reassessment of
risk factors and evidence of asymptomatic target organ
damage. The ESC/ESH CPG recommends achieving
BP control within 3 months of initiating therapy, further
emphasizing the need to consider initial therapy with
combination drugs in most patients to achieve rapid BP
control.
Both guidelines provide detailed guidance for detec-
tion and management of secondary hypertension,
definition and management of resistant hypertension,
hypertensive urgencies and emergencies, masked and
white coat hypertension, hypertension in older adults,
men and women, persons of different race/ethnicity,
and patients with various comorbidities and conditions,
including heart disease, cerebrovascular disease, CKD,
peripheral vascular disease, DM and metabolic syn-
drome, aortic disease, and pregnancy.
Both guidelines focus considerable attention on
strategies to improve adherence to therapy, empha-
sizing the advantage of single-pill combinations to
improve adherence and overcome therapeutic inertia,
and team-based care. Both guidelines also focus on
implementation, that is, models for delivery of care, use
of health information technology, improving quality of
care, health literacy, access to care, social and com-
munity services, and a patient-specific plan of care. The
ESC/ESH provides recommendations for treatment
of isolated systolic hypertension, and it recommends
reserving device-based treatments of hypertension
for research settings. The ESC/ESH provides recom-
mendations for managing concomitant CVD risk with
specific recommendations for the use of statins, anti-
platelet drugs, and oral anticoagulation (in atrial fibril-
lation), whereas the ACC/AHA largely defers to other
ACC/AHA guidelines that cover these topics. Last,
both guidelines identify gaps in evidence and provide
a summary key message (ESC/ESH) or BP treatment
thresholds and goals (ACC/AHA).

Figure 2. Blood pressure thresholds for initiation of blood pressure–lowering therapies in the 2017 ACC/AHA and 2018 ESC/
ESH blood pressure guidelines.
ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP,
blood pressure; CAD, coronary heart disease; CVD, cardiovascular disease; ESC, European Society of Cardiology; ESH, European Society of
Hypertension; and HMOD, hypertension-mediated organ damage. Adapted from Whelton et al1 with permission. Copyright © 2018, Elsevier; and
Williams et al2 with permission. Copyright © 2018, Oxford University Press.

Circulation. 2022;146:868–877. DOI: 10.1161/CIRCULATIONAHA.121.054602 September 13, 2022 875

 Whelton et al
REFLECTIONS
STATE OF THE ART
Although differences in guidelines are invariably high-
lighted, it is notable that the core advice in the ACC/AHA
and ESC/ESH guidelines is remarkably similar in most im-
portant areas of practice (Table 9). Even for the area of
greatest difference, the definition of hypertension, there
is still considerable overlap. In both guidelines, adults with
an average SBP ≥140 mm Hg or DBP ≥90 mm Hg are
designated as having hypertension and treatment with a
combination of lifestyle counseling and antihypertensive
drug therapy is recommended. Those with an average SBP
130 to 139 mm Hg are designated as having stage 1 hy-
pertension in the ACC/AHA and high normal BP in the
ESC/ESH. However, both guidelines recommend lifestyle
modification for most adults in this BP category, the ad-
dition of antihypertensive drugs only being recommended
for the ≈30% of US adults with CVD or a 10-year AS-
CVD risk ≥10% in the ACC/AHA guideline and only to
be considered in very-high-risk patients, especially those
with coronary artery disease, in the ESC/ESH CPG. For
many other treatment differences, the 2 guidelines provide
overall advice that is similar but sometimes discrepant in
the specifics. For example, both guidelines recommend
combination antihypertensive drug therapy but the specific
application for this advice is somewhat different. The ESC/
ESH places great emphasis on single-pill combination
drug therapy, whereas the ACC/AHA encourages single-
Table 9. Similarities and Differences in the 2017 ACC/AHA and 2018 ESC/ESH Adult BP Guidelines
Similarities
Comprehensive guidelines based on rigorous development
processes
Emphasis on accurate BP measurements and use of out-of-office
readings
Use of CVD risk estimation to inform decision for initiation of anti-
hypertensive drug therapy
Similar lifestyle change recommendations for prevention and
treatment of hypertension
Antihypertensive drug therapy recommended when SBP ≥140
mm Hg or DBP ≥90 mm Hg in both guidelines
Similar core strategy for antihypertensive drug therapy
Combination therapy for most adults with hypertension
Single-pill combinations preferred
 If no compelling indication for drug choice, consider initial
2-drug combination of diuretic or calcium channel blockers plus
angiotensin converting enzyme inhibitors or angiotensin recep-
tor blockers, followed by a 3-drug combination if necessary
Lower BP targets compared with previous guidelines
Strategies to improve adherence and BP control
ACC indicates American College of Cardiology; AHA, American Heart Association; BP, blood pressure; CVD, cardiovascular dis-
ease; ESC, European Society of Cardiology; ESH, European Society of Hypertension; DBP, diastolic blood pressure; and SBP,
systolic blood pressure.
876 September 13, 2022 Circulation. 2022;146:868–877. DOI: 10.1161/CIRCULATIONAHA.121.054602
ACC/AHA and ESC/ESH Blood Pressure Guidelines
pill combinations when possible but notes that many of the
combination pills available in the United States use hydro-
chlorothiazide rather than chlorthalidone and often use a
diuretic dose that is lower than what has been used in the
landmark treatment trials. Likewise, both guidelines recom-
mend a lower BP target during treatment compared with
what was advised in previous guidelines, including in older
adults. Overall, the difference lies in the ESC/ESH taking
a more stepped approach, first recommending achieve-
ment of an SBP/DBP <140/90 mm Hg before targeting
a lower BP, if tolerated, and identifying SBP 120 mm Hg
and DBP 70 mm Hg as the lower safety boundary for BP
reduction in adults 18 to 65 years of age (130 mm Hg in
those with CKD). The ACC/AHA recommends a single
SBP/DBP target of <130/80 mm Hg in most adults but
SBP <130 mm Hg in older well adults, if tolerated.
Some of the differences between the 2 guidelines
reflect the CPG process requirements of the ACC/AHA
and ESC/ESH. For example, the composition of the 2 writ-
ing committees, the approach to management of potential
conflicts of interest, and the ACC/AHA use of an indepen-
dent evidence review committee are all a direct result of
ACC/AHA and ESC/ESH guideline process requirements.
Other differences between the 2 guidelines reflect the
fact that they were written for different populations/geo-
graphic regions. A good example of this is CVD/ASCVD
risk estimation, where evidence suggests that risk-estimat-
ing tools that have been validated in 1 population may not
Differences
Lower SBP and DBP cut points for diagnosis of hypertension in
ACC/AHA guideline
ACC/AHA recommends antihypertensive drug therapy when SBP
130–139 mm Hg or DBP 80-89 mm Hg and CVD or 10-year ath-
erosclerotic CVD risk ≥10%, whereas ESC/ESH recommends drug
therapy only be considered for SBP 130–139 mm Hg or DBP 85–
89 mm Hg when CVD present, especially coronary heart disease
BP targets somewhat lower in ACC/AHA than in ESC/ESH, es-
pecially in older adults and those with chronic kidney disease.
Treatment of other CVD risk factors recommended in both guide-
lines but ACC/AHA references other ACC/AHA guidelines for
specific details, whereas ESC/ESC includes details for statin and
aspirin therapy.
Whelton et al
perform as well in another practice setting. Some of the
differences reflect different weighting and interpretation
of the available research findings by the 2 writing com-
mittees. For example, the ESC/ESH placed less emphasis
on the SPRINT (Systolic Blood Pressure Intervention Trial)
findings, and on meta-analysis (especially network meta-
analysis). Last, some of the differences probably reflect
variations in practice culture and organization of the health
care systems in the United States and Europe.
RECOMMENDATIONS
Despite assertions to the contrary,9 there is greater con-
gruity between the 2017 ACC/AHA and 2018 ESC/
ESH CPGs than previous BP guidelines on each side
of the Atlantic. Additional harmonization of the 2 guide-
lines in the future would be helpful. Ways to achieve this
goal could include the use of processes that better ap-
proximate each other, liaison membership from each writ-
ing committee to the other, temporal synchronization of
guideline preparation allowing ongoing communication
between writing committees, structured open discus-
sion of the science underpinning recommendations by
the writing committees and sharing systematic reviews
related to key questions, peer review of each report by
members of the other guideline writing committee, and
joint presentations/publications, such as the one provided
here, to compare the ACC/AHA and the ESC/ESH rec-
ommendations and to place them in the context of the
populations and practice communities for which they are
being written. Much of this is already happening to some
extent, but it is informal and would likely benefit from a
more structured approach. The ACC/AHA and ESC/ESH
guidelines have a common purpose of assisting clinicians,
the public health community, and the public in achiev-
ing the goal of better health. Current rates of treatment
and control of hypertension, however defined, remain
suboptimal in Europe and the United States. The more
convergent the major American and European guideline
recommendations are with each other, the more unified
the message to patients, clinicians, professional societies,
governmental agencies, and the public. Greater congru-
ence would thus be expected to underscore a common
purpose and command the attention necessary to cata-
lyze changes in practice leading to improvement in hyper-
tension awareness, treatment, and control in the future.
ARTICLE INFORMATION
Affiliations
Department of Epidemiology (P.K.W., J.D.B.), Tulane University School of Public
Health and Tropical Medicine, and Department of Medicine, Tulane University
School of Medicine, (P.K.W.), New Orleans, LA. Division of Endocrinology and
Metabolism, Department of Medicine, University of Virginia School of Medicine,
Charlottesville (R.M.C.). University of Milano-Bicocca, Milan, Italy (G.M.). Charité-
Circulation. 2022;146:868–877. DOI: 10.1161/CIRCULATIONAHA.121.054602
ACC/AHA and ESC/ESH Blood Pressure Guidelines
Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Hum-
boldt-Universität zu Berlin, and Berlin Institute of Health, Department of Clinical
Pharmacology and Toxicology, Germany (R.K.). UCL Institute of Cardiovascular
STATE OF THE ART
Sciences, University College London, United Kingdom (B.W.). National Institute
for Health Research, UCL Hospitals Biomedical Research Centre, London, Unit-
ed Kingdom. (B.W.).
Sources of Funding
Dr Whelton was supported by a Centers for Research Excellence grant from the
National Institute of General Medical Sciences (P20GM109036). Dr Carey was
supported by National Institutes of Health grants R01-HL-128189 and P01-
HL-074940. Dr Kreutz was supported by Deutsche Forschungsgemeinschaft
(German Research Foundation), Project number 394046635–SFB 1365. Dr
Williams was supported by the National Institute for Health Research, UCL Hos-
pitals Biomedical Research Center.
Disclosures
Dr Mancia reports personal honoraria from Boehringer Ingelheim, Ferrer, Gedeon
Richter, Medtronic Vascular Inc, Menarini Int, Merck Healthcare KGaA, Neo-
pharmed-Gentili, Novartis Pharma, Recordati, Sanofi, and Servier during the two
years before submission of the manuscript. Dr. Kreutz reports support of research
by Bayer and personal honoraria from Bayer, Berlin-Chemie Menarini, Daiichi
Sankyo, Ferrer, Merck, Sanofi, and Servier outside this work. Dr. Williams reports
an investigator research grant from Omron, Japan, and Vascular Dynamics Inc
USA. and lecture honoraria from Daiichi Sankyo, Pfizer, Boehringer and Servier
outside this work. The other authors report no conflicts.
Supplemental Material
Supplemental Tables S1–S3
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